L 40 Flashcards
What does VTE stand for?
Venous thromboembolism. (Vain)
What are the 2 types of VTE?
Deep vein thrombosis (DVT)
Pulmonary embolism (PE)
Where do the clots form in VTE?
Where do they form?
What colour are these clots/what are they rich in?
Clots form in the vein due to blood stagnation/in vessel wall/ cause valve damage
They are fibrin rich clots, aka ‘red clots’
What is the difference between Red and White clots?
Red clots: fibrin rich. Caused by stagnation of blood
White clots: platelet-rich. Caused by atherosclerosis.
Risk factors for VTE:
What are the complications of VTE?
Age
History of VTE
Venous stasis (illness, surgery, obesity, varicose veins)
Vascular injury (trauma, major surgery e.g knee replacement)
Hypercoagulopathy
Drugs (e.g estrogen, tranexamic acid)
chronic Venous insufficiency (eg. oedema cellulitis venous ulceration)
What are some causes of hypercoagulopathy x3
Cancer, abnormal clotting factor concentration, pregnancy
What is DVT? and PE?
Signs and symptoms of DVT
What is the test of DVT ?
DVT is a thrombus is blocking a deep VAIN(ex:abdomen, leg)
PE is a thrombus or embolus blocking the ARTERY
- Unilateral(one side) leg swelling (edema, pain, warmth, erythema)
- Positive homans sign (pain when ankle is dorsiflexed)
- Clot detectible through Duplex ultrasound.
D-dimer Test (product of fibrin breakdown, elevated when there is a clot)
Signs and symptoms of PE
- Cough, chest pain/tightness, palpitations.
- Dizziness
- Elevated D-dimer
- May be preceded by signs and symptoms of DVT
- Clot detectible via ventilation/perfusion scan or CT scan
Orthopnoea
Shortness of breath when lying down
Haemoptysis
Coughing up blood
Principles of VTE treatment x5
- Detect VTE early
- Prevention/prophylaxis(action taken) of events and complications early
- Prevent further clots/emboli
- concentrate on Re-vascularise/re-perfuse
- Avoid adverse drug treatment effects (e.g bleeding!!)
What drug class breaks down the thrombus?
Fibrinolytics
which drug class prevents the propagation of a thrombus and long-term disease recurrence?
Anti-coagulants
What would be the Immediate treatment for hemodynamically unstable PE patients?
What is the test available for PE clot?
IVF, O2, vasopressors, ventilation and may require resuscitation before treatment for the PE itself
Ventilation /perfusion V/Q
or CT scan
Immediate treatment for PE patients (after haemodynamic stabilisation)
Alteplase 10mg IV bolus over 20 mins + 90mg IVI over 2 hours
What is alteplase?
A recombinant tissue plasminogen activator (rt-PA)Short term treatment for VTE (~5 days)
What does UFH bind to and what does LMWH bind to?
UFH: Thrombin and Xa and IIa
LMWH: Thrombin and Xa
VTE treatment long term (3month+)
Varies dependent on risk factors related to clotting.
- Warfarin: 3-5mg OD then adjusted as per INR
- Dabigatran: 150mg bd. Adjust if elderly or Crcl impaired as can’t monitor.
- Rivaroxaban (+ apixaban but not yet funded): 15mg bd for 3 weeks then reduce the dose to 20mg OD
Which medicines can you not monitor for VTE?
Dabigatran and rivaroxaban
pros and cons of Warfarin and NOACs?
Similar effectiveness, all have a narrow therapeutic window.
Warfarin: is cheaper, slower onset of action, longer t0.5 (more forgiving), can be measure so can be guided by INR, can be REVERSED by VitK
NOACs: expensive, faster onset of action, Can not be monitored required, the effect can’t be readily reversed ($$$)
What is heparinisation?
Giving heparin to a patient. That can be Sometimes by infusion.
VTE is an important medical condition with potential consequences and what are they?
With what we can treat DVT and PE with anticoagulants?
During VTE therapy what are the risks?
What type of therapeutic window do anticoagulants have? do they need monitoring?
Thrombus/embolism formation inside a vein, and is a fibrin-rich red clot.
Both DVT and PE are treated with anticoagulants acutely and long term. But Some PE patients would also require thrombolytics
risk of bleeding and the risk is even higher when this therapy is thrombolytics.
All anticoagulants have a narrow therapeutic window. Adherence and monitoring/recognition of adverse effects is very important.
With what we can measure Unfractionated heparin
aPTT test
and then according to result, we adjust the dose.
With what we can measure Low Molecular weight heparin? Ex: enoxaparin
Anti-Xa test
How to give UFH heparin dose?
IV bolus or infusion
How adjust LMWH heparin dose?
according to CrCL if it is low
What based on treatment DURATION based on what for Thromboembolism?
BAsed on risk factors , site of cloth, risk factors, and whether it was provoked
What would be the initial dose of warfarin?
OD start with 3 to 5 mg
then adjust the dose according to the INR result
Does Apixaban is funded?
NO
